Monday, May 25, 2009

Five-inch stilettos, too-heavy handbags, a wedding dress that seemingly weighed as much as a small child — Parmeeta Ghoman admits she's no stranger to suffering for fashion. "I'm the kind of person who buys shoes two sizes too small just because they're cute — and they're on sale," says Ghoman, who's 28 and lives outside of San Francisco.

But when she wore a pair of super-tight skinny jeans to dinner with friends in December, she noticed an odd tingly sensation running up and down her thighs. And when she got up to walk around, things got weirder. She felt like she was almost "floating," because she couldn't feel her legs. "It felt really strange — it felt like my leg had gone to sleep," Ghoman says.

Ghoman's skin-tight denim may have caused a temporary bout of a nerve condition called meralgia paresthetica, also known as "tingling thigh syndrome." The condition can happen when constant pressure — in Ghoman's case, from the skin-tight denim — cuts off the lateral femoral cutaneous nerve, causing a numb, tingling or burning sensation along the thigh.

Wednesday, May 13, 2009

Pain is the most prominent member of a class of sensations known as bodily sensations, which includes itches, tickles, tingles, orgasms, and so on. Bodily sensations are typically attributed to bodily locations and appear to have features such as volume, intensity, duration, and so on, that are ordinarily attributed to physical objects or quantities. Yet these sensations are often thought to be logically private, subjective, self-intimating, and the source of incorrigible knowledge for those who have them. Hence there appear to be reasons both for thinking that pains (along with other similar bodily sensations) are physical objects or conditions that we perceive in body parts, and for thinking that they are not. This paradox is one of the main reasons why philosophers are especially interested in pain. One increasingly popular but still controversial way to deal with this paradox is to defend a perceptual or representational view of pain, according to which feeling pain is in principle no different than undergoing other standard perceptual processes like seeing, hearing, touching, etc. But there are many who think that pains are not amenable to such a treatment.

Tuesday, May 12, 2009

Few people think twice about taking aspirin or ibuprofen. But for those 75 and older, the high doses needed to treat chronic pain may be so dangerous that patients may be better off taking opioids instead, an expert panel has found.

New pain management guidelines issued by the American Geriatrics Society late last month removed those everyday medicines, called Nsaids, for nonsteroidal anti-inflammatory drugs, from the list of drugs recommended for frail elderly adults with persistent pain. The panel said the painkillers should be used "rarely" in that population, "with extreme caution" and only in "highly selected individuals."

Acetaminophen (like Tylenol) remains the top choice for treating chronic pain, but for those patients unable to get relief, the next step on the ladder is opioids, the guidelines say — as long as patients and their caregivers are screened for previous substance abuse.

The recommendation, which is already proving controversial, was made even though Nsaids are known to be fairly effective for chronic inflammatory pain conditions that often plague older adults, and even though opiates can be addictive.

"We've come out a little strong at this point in time about the risks of Nsaids in older people," said Dr. Bruce Ferrell, a professor of geriatrics at U.C.L.A. who is chairman of the panel. "We hate to throw the baby out with the bathwater — they do work for some people — but it is fairly high risk when these drugs are given in moderate to high doses, especially when given over time.

"It looks like patients would be safer on opioids than on high doses of Nsaids for long periods of time," he continued, adding that for most older people, the risk of addiction appears to be low. "You don't see people in this age group stealing a car to get their next dose."

But experts on pain say that it is difficult to make generalizations and that extreme caution must be used in prescribing opioids, no matter what the age of the patient.

"We're seeing huge increases nationwide of reports about the misuse and diversion of prescription drugs and related deaths," said Dr. Roger Chou, a pain expert who was not involved in writing the guidelines for the elderly but directed the clinical guidelines program for the American Pain Society. "The concerns about opioids are very real."

There is also a concern about side effects that may be associated with opioid use, including respiratory problems, constipation, fatigue and nausea, Dr. Chou said.

Many of the panelists reported having financial ties with drug manufacturers, but the chairman, Dr. Ferrell, said that he had no conflicts of interest regarding the medications under discussion and that the guidelines were peer-reviewed.

Dr. Ferrell acknowledged that scientific evidence on addiction among the elderly was limited because few studies focus on people 75 and older. The risks of Nsaids include ulcers and gastrointestinal bleeding and, with some drugs, an increased risk of heart attacks or strokes. The drugs do not interact well with medicines for heart failure and other conditions, and may increase high blood pressure and affect kidney function, experts said.

The guidelines are not meant to discourage the treatment of pain. Experts involved in developing the guidelines say chronic pain takes a huge toll on the elderly and too often goes untreated.

The new guidelines are also not meant to affect recommendations about taking baby aspirin to protect the heart; the amount of aspirin — 81 milligrams — is very small, a quarter of the dose contained in an adult pill.

Monday, May 11, 2009

During the last 20 years fundamental research into nociceptive mechanisms and clinical trials of pain therapy has established the psychology of pain as an essential component of both research and treatment. Research into neuroplasticity of the nervous system offers a challenging perspective on the complex processes involved in pain perception and demonstrates that psychological factors are of fundamental importance in mediating pain processing. All pain has a psychological component and psychological factors are important at all stages in pain (whether the problem is acute, recurrent or chronic) and have a major role in the prevention of unnecessary pain-associated dysfunction in a wide range of settings from primary prevention to terminal care.

Although the specific roles of psychologists vary in different countries, the rapid advances in pain psychology offer major new opportunities in research, teaching, clinical practice and social policy.

Psychological assessment has now expanded considerably from the assessment of personality structure and detection of psycho-pathology to much wider psychosocial perspectives, including consideration of influences on symptom presentation and response to treatment.

Psychological intervention has moved from individual psychological therapy to include also group treatment and interdisciplinary pain programs. In the latter, psychologists may find themselves in managerial as well as clinical roles.

The investigation of fundamental psychological mechanisms has expanded from its foundations in psychophysics and animal-based experimentation to the examination of psychobiological investigations into relationships between the peripheral and central nervous systems. Curriculum on Pain for

Currently pain psychologists are employed in a wide range of settings, ranging from fundamental research to health care delivery. In education and teaching, psychologists are increasingly asked to prepare and participate in lectures, courses and teaching curricula on pain; ranging from introductory talks to highly specialized professional training, but psychology training often fails to address the special problems of working with pain patients.

The purpose of this curriculum is to equip psychologists to meet each of these challenges.

People suffering from chronic low back pain who received acupuncture or simulated acupuncture treatments fared better than those receiving only conventional care According to a recent study published in the Archives of Internal Medicine.[1] The study highlights central questions about the mechanisms of benefit seen in acupuncture studies.

This trial, led by Daniel Cherkin, Ph.D., of Group Health Center for Health Studies in Seattle, was funded by the National Center for Complementary and Alternative Medicine (NCCAM), a component of the National Institutes of Health.

"Because of the lack of highly effective medical treatments for chronic low back pain, we were pleased to find that acupuncture-like treatments were helpful for persons suffering from chronic back pain," said Dr. Cherkin. "However, the finding that real acupuncture produced no greater benefit than simulated acupuncture raises important questions about acupuncture's mechanisms of action."

This trial enrolled 638 adults with chronic low back pain who had never had acupuncture and who had rated the "bothersomeness" of their pain as at least a 3 on a 0-to-10 scale. The participants were randomly assigned to one of four groups: individualized acupuncture, involving a customized prescription for acupuncture points from a diagnostician; standardized acupuncture, using a single prescription for acupuncture points that experts consider generally effective for chronic low back pain; simulated acupuncture, which mimics needle acupuncture but does not involve actual penetration of the skin; or usual care, which is standard medical care.

The patients assigned to any of the three acupuncture groups (individualized, standardized, or simulated) were treated twice weekly for three weeks, and then weekly for four weeks. At 8, 26, and 52 weeks, researchers measured back-related dysfunction and how much symptoms bothered participants.

The researchers found that at eight weeks the individualized, standardized, and simulated acupuncture groups all improved their dysfunction scores significantly more than the group receiving usual care. These benefits persisted for one year, though diminished over time. However, there was no significant difference between the groups receiving the needle and simulated forms of acupuncture. Thus, while acupuncture was found effective in treating low back pain, neither tailoring acupuncture needle sites to an individual patient nor penetrating the skin appears to be important for receiving therapeutic benefit.

"The findings of this research show that acupuncture-like treatments, including simulated acupuncture, can elicit positive responses," said Josephine P. Briggs, M.D., director of NCCAM. "This adds to the growing body of evidence that there is something meaningful taking place during acupuncture treatments outside of actual needling. Future research is needed to delve deeper into what is evoking these responses."

The researchers believe that further research is needed to determine the roles of patient expectancy, practitioner reassurance and the physiological effects of non-insertive stimulation and other effects that may contribute to acupuncture-like benefits.

Thursday, May 07, 2009

A back-pain researcher, Dr. Richard Deyo recalls the uproar the last time federal officials tried to suggest how doctors should practice their profession.

It was in the mid-1990s, when Dr. Deyo helped develop federal guidelines urging surgeons not to perform spinal fusions to treat acute pain. The reason was simple: There was little evidence that the fusions worked in many patients.

Spine specialists quickly attacked the report, calling it flawed. One medical device maker, Medtronic, sued unsuccessfully to block its release. Republican lawmakers tried to kill the agency that issued the report. It survived, but its funding was drastically cut, and it decided to stop issuing guidelines.

Now, 15 years later, the Obama administration is entering this same medical minefield. And once again, opponents are gearing up for a fight.

The administration plans to spend $1.1 billion over the next few years on studies like the one conducted by Dr. Deyo, to compare the effectiveness of competing treatments for common conditions like back pain, heart disease and prostate cancer. The studies will be publicly released, to help doctors and patients decide which treatment options they want to pursue.

Supporters include many medical researchers, consumer groups, unions and insurers. They say such studies are essential to curbing the widespread use of ineffective treatments and to helping control health care costs, which totaled $2.2 trillion in 2007, or 16 percent of the nation's gross domestic product.

But potential opponents — which include medical products companies, some doctors and their political allies — warn that the comparative effectiveness movement could lead to inadequate treatment for some patients and even the rationing of health care.

"It is not difficult to see how you can get on a slippery slope very easily," said Tony Coelho, a former Democratic congressman who is head of a new industry-backed Washington group called the Partnership to Improve Patient Care, formed to lobby on the comparative effectiveness effort.

The group's backers include major trade organizations that represent producers of drugs, medical devices and biological treatments.

Critics like Mr. Coelho also point to a British government agency, the National Institute for Health and Clinical Excellence, or NICE, which considers costs in judging a treatment's effectiveness. Based on NICE's findings, the British government has denied some patients access to costly drugs like those used to treat cancer.

Whether cost should be a factor in this country was a hot-button issue during the Congressional debate in February, when the comparative-effectiveness funding was approved as part of the economic stimulus package. A legislative report by Congressional lawmakers who negotiated the final version of the bill said that they did not intend the research money to be used to "mandate coverage, reimbursement or other policies for any public or private payer."

Despite that assurance, even supporters of the effort say one goal in identifying effective medical treatments is to stop wasting money on those of little value.

Beginning on Wednesday, May 6th, APS President Chuck Inturrisi will be sending updates on the 28th Annual Scientific Meeting from San Diego! If you are unable to attend, we invite you to follow the meeting through his perspective.

The American Pain Society (APS) is the leading multidisciplinary organization of basic and clinical scientists, practicing physicians, policy analysts, and other leaders in the study and treatment of pain. With over 3,000 highly skilled and trained members specializing in pain, APS is the premiere source to reach professionals within in this specialized field.

The APS Career Center provides current information for healthcare specialist in the field of pain treatment as well as being a resource for exciting new careers. Here are the benefits for job seekers and employers.

Monday, May 04, 2009

"One of the best blogs in medicine is Ves Dimov's Clinical Cases and Images - Blog. It contains a rich collection of "presurfed" material for busy clinicians and features interactivity and timely discussion. Dimov is also a supporter of medical librarian bloggers. Why waste time fumbling with search engines when you can consult this blog for timely updates? As well as case discussions, Ves provides links to today's medical headlines from Reuters and clinical images via a dynamic, free photo sharing tool called Flickr. One of his slide presentations "Web 2.0 in medicine" is available on Slideshare (itself a fantastic new 2.0 tool). Clinical Cases and Images is a virtual laboratory for doctors and medical librarians interested in Web 2.0."